Case Presentation
RCC Dental Hygiene Program
DEH-11
Shari Stuart
Case Presentation
Patient Profile: Ms. Case is a 98 year old female. She is retired. Her daughter Suzie Case is her
emergency contact with her phone number provided. Her physician’s name and number is also
provided.
Chief complaint: The Patient states that “she is here to get her teeth cleaned”.
Dental History: The Patient states that her previous dentist is Dr. Dentist. In Aug. of 2000, she had an
exam, FMX, and her teeth cleaned.
Medical History: My pt. denies any past or present cardiovascular, respiratory, Head & Neck or social life
problems. My pt. states that she has problems walking and she had RT. Hip replacement surgery in
1999. My pt. also states that she had knee surgery in Sept. 1974. She tore a ligament, while playing
softball. My pt. denies any past or present gastrointestinal/Genito-uninary problems, STD’s,
Hema/Endo/Immune disorders, Psyschological problems. My pt. states that she has received her
childhood and Hepatitis B vaccination. My pt. states she is post menopausal. My pt. states she is allergic
to penicillin and sulfa drugs. My pt. denies any past or present family disease history.
Medication:
Lipitor- period taken for: 2 mo. Dose: 10mg 1x/day every evening. It is used to reduce elevation in total
cholesterol. Dental implication: No significance effects or complications. Dental Contraindications: No
information available to require special precautions.
Appt # 1 - I went over pt. medical history and medications with her. I was approved by instructor to
proceed with her E&I. I gave her an E&I and took her vitals. Her Bp : 125/80, P : 80, R : 17. ASA 2.
Her gingival description: color – attached/free gingival was generalized erythmatous.
Marginal gingival: pink Contour: bulbous
texture: shinny/glossy
MBI: 7% BOP: %, periodontal probing : localized 2-3 mm on # 19-29 and generalized 4-6 mm pockets
in all other teeth: facial and lingual surface. OHI was provided. I taught my pt. the bass tech. and how to
floss 2x/day. I also explained perio disease and that her perio disease is at a moderate level, and she has
deep pocket probing depts., and how her and I can help try to make her tissues heal. Then she had a
DDS exam. Dr. confirmed that Pt. has decay on # 3 on occusal surface –class 1. # 6 &11 on lingual
surfaces –class 5. # 20 DO surface decay –class 2. Wisdom teeth not erupted.
Appt #2 – 2nd check in. RMH, no changes. Her Bp: 123/79 P: 76 R: 19. Her PI: 47%. OHI was provided. I
recommended for her to be sure to brush and floss morning and night. I taught her the Bass technique
and how to properly floss.
Appt #3 – RMH, E&-I no changes. I took her vitals and her Bp: 125/77. P: 75 R: 18. Scaled upper Right
maxillary quadrant, with (ASA)&(NP) anesthesia. It was given for facial and lingual surfaces for teeth # 6,
7, 8. I recommended a Chlorhexidine rinse to use every night at bed time to help reduce the bacteria for
her 6mm pockets.
Appt# 4 – RMH, E&I. No changes. Her vitals BP: 121/77. P:75 R:19. I Scaled the Lowser Right mandibular
quadrant.
Appt #5 – RMH, E&I- No changes. Her vitals BP: 122/76. P: 74 R: 16. I scaled the upper Left maxillary
quadrant, with ASA and NP anesthesia. It was given for facial and lingual surfaces for teeth # 9, 10, 11.
Appt # 6 – RMH, E&I. NO changes. Her vitals BP: 128/82, P: 77 R: 18. I scaled the left mandibular
quadrant. I gave her a fluoride treatment, & selective polishing on her anterior of both arches, and her
1st and 2nd molars of both arches on all surfaces.
Appt# 7 – 3 mo. Recall appt. RMH, E & I no changes. Bp: 137/82 P: 88 R: 16
ASA-2. OHI – I
reviewed the bass techinique and floss instructions with my patient. Her PI was at 35%. So She is doing
much better.